Employee Fingerprint Forms

Employee Fingerprint Authorization and Consent Form

Personal Information

Date of Birth:    Last 4 of SSN:    Driver's License #:

Position & Employment Information

Reporting Manager:    Start Date:

Full-time    Part-time    Temporary    Contractor

Fingerprint Collection Details

Reason for fingerprinting: New hire    Background check    Licensing/certification    Promotion

Rolled impressions    Flat/plain impressions    Livescan / Electronic capture

Technician Name:    Collection Date:

Transaction / Device ID:    Fingerprint Card #:

Right Thumb    Right Index    Right Middle    Right Ring    Right Little

Left Thumb    Left Index    Left Middle    Left Ring    Left Little

Criminal History Disclosure

Have you ever been convicted of, plead guilty to, or plead nolo contendere to any felony or misdemeanor (excluding minor traffic violations)?    No    Yes

Authorization and Consent

I authorize the employer and its designated agents to submit my fingerprints and personal identifying information to authorized local, state, and national agencies for the purpose of obtaining criminal history, state and federal records, and other information required for employment or licensing suitability determinations. I understand that these records may include convictions, arrests pending disposition, and other relevant information.

I acknowledge that fingerprints and related information may be retained by authorized agencies and used for subsequent checks in accordance with law. I understand that a criminal history report may be used in whole or in part to make employment decisions and that some convictions may disqualify me from employment or placement in certain positions.

By checking the box below I expressly consent to fingerprinting, background checks, and the release of records as described above.    I consent

Employment History (Most Recent)

Title:    Dates Employed:

Employment History (Previous)

Title:    Dates Employed:

Education

References

Legal Notices & Authorization

At-Will Employment: I understand and acknowledge that, unless otherwise provided in an express written agreement signed by an authorized representative of the employer, my employment is at-will and may be terminated by either party at any time, with or without cause or notice.

Equal Opportunity Statement: The employer provides equal employment opportunity to all applicants and employees without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other protected characteristic as required by applicable law.

Authorization to Contact: I authorize the employer to contact any listed references and prior employers to verify the information I have provided. I release all parties from liability for providing truthful information in response to such inquiries.

Applicant Certification

I certify under penalty of perjury that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that any misrepresentation or omission may result in denial of employment, termination of employment, or revocation of a license.

I understand that the fingerprinting and background check results will be used only for authorized employment or licensing purposes and will be handled in accordance with applicable privacy and record retention laws. I further understand that I may be required to provide additional information or documentation to resolve any record discrepancies.

By checking the box below I certify the statements above and authorize fingerprint submission and background checks.    I certify and authorize

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